The benefits and challenges of commercial repatriations
Oliver Cuenca talks to repatriation experts about the benefits and challenges of transporting patients on commercial flights, building relationships with airlines and managing kit in small cabin spaces
The world of medical repatriations is diverse, and while many patients choose to be transported via private aircraft, transfers via commercial airliner remains a popular and cost-effective alternative.
For Ariel Mauer, Chief Paramedic at MedAssis, a key benefit of conducting a medical repatriation via commercial airliner is the higher level of comfort offered to the patient through shorter journey times and the company of loved ones. “There is the possibility of having one or more family members there as part of the escort, which can be very comforting in an otherwise stressful situation,” he said. “And the longer the transport, the more the convenience factor tips to the advantage of the commercial flights, where with good planning and a bit of luck, you have no need to land in the middle of the flight for refuelling, for example.”
According to Carl Era, Flight Nurse Co-ordinator at Capital Air Ambulance, other benefits include lower costs and higher speed: “If the carrier allows us to get the patient to their destination more quickly and directly than an air ambulance, then that will be preferable. Cost is also a major factor – in general, commercial flights are less expensive than a dedicated air ambulance. Where the patient has extensive family members who wish to travel with them, and/or excessive luggage, using the commercial option may be more appropriate due to space.”
Marcie Harrison, Chief Flight Nurse at LIFESUPPORT Air Medical Services, agreed, but added that while ‘the airlines are always very welcoming to us and provide exceptional support, commercial travel is now presenting challenges with oversold routes and generalised airport chaos’.
More comfort for patients, more stress for staff
While patient comfort may be increased significantly when employing a commercial airline for transport, the tradeoff can often be felt through greater challenges for medical staff.
For Harrison, the level of consideration involved typically depends on the patient. She explained: “Sometimes it can be simple and straightforward – wheelchair access and off you go! Other times, the complicated logistics involved in moving a critical care patient onboard a commercial aircraft can be daunting. It isn’t something just anyone can or should attempt to do.
However, she added: “Speaking from personal experience, the most challenging part is simply getting through airport security and customs with medical equipment. Negotiation skills are so essential!”
Era agreed: “Logistically, I think most operators would agree that moving patients on commercial aircraft is more challenging than using a dedicated air ambulance.” Key reasons, he says, include the challenges of negotiating with crowds, airport security, and potential delays or cancellations, adding that: “Carrying medical kit through the airport is also susceptible to delays as security and check-in staff are frequently unfamiliar with the equipment we carry and volumes of fluid we move exceeds what is generally permissible.”
A key benefit of private air ambulances over commercial flights is the lack of an external, airline-operated medical clearance desk
Era added that some drugs, such as opioids, can be such a serious concern in many countries that ‘we do not allow our escorts to take them on commercial missions’, with crews required to source them locally in the jurisdictions in which they land. “Occasionally, even with the accompanying paperwork which we send on all missions, staff are reluctant to allow it onboard and it often requires a manager or someone higher up the chain of command to intervene,” he said.
He recommended acquiring ‘covering letters’ for medical equipment to expedite such potential disruption, or potentially pre-warning security before arrival at airports that are known to be ‘problematic’.
Once onboard, Era said: “We then have to get the patient from the door to their seat in a confined space and store the kit whilst ensuring we have easy access to it. We will usually have requested assistance from the airline, but ensuring that all this kit remains with you is challenging.”
“Most companies request an escort and again this can be problematic,” he said, adding that Capital’s medical escorts will typically ‘carry their own overnight bag, a portable oxygen concentrator (POC) and accompanying batteries, and a medical kit’. This is on top of the often ‘sizeable’ luggage often belonging to the patients themselves.
“Obviously, commercial aircraft are not purpose-built for these jobs, which means that we have to arrive [at the airport] completely ready to solve all eventualities,” Mauer agreed. He added that being ‘fully ISO certified’ and having a ‘closely managed and updated’ inventory of medical equipment are both key to his staff feeling ‘comfortable taking on most cases in a commercial aircraft’.
Other challenges of medical repatriation
Beyond just getting equipment onboard, commercial flight repatriation can pose other challenges for both crew and patient, including:
- The disruption of circadian rhythms – which can have a negative impact on patient health as well as the ability of medical crew to perform their duties
- The exhausting nature of waiting periods between connecting flights, including delays
- The challenges of ‘toileting’ a person with limited mobility or faculties confined spaces, particularly when considering the issue of privacy.
Era said that to manage such challenges, ‘preparation is key to making the transfer as smooth as possible, [including] furnishing the airline with any necessary information they require’. He said that working with the airline during the booking process will usually result in the cabin crew being alerted to the needs of the medical crew and patients.
Some patients needed such bulky equipment that they were automatically excluded from transportation by commercial flight
In addition, ‘requesting aisle seats near to the toilet and with extra leg room really does help to overcome mobility issues’. In addition, he recommended: “Where possible, booking a direct flight is preferable as boarding is often the most stressful part of the journey … and [where] connections are necessary, we will always aim to leave sufficient time for an orderly transfer and to allow for any delays.
“I think mitigation is the key word here,” he added. “Where possible, we try to book business class seats as there is generally more space to negotiate with, the seats are more comfortable for the patient, there are fewer people in the cabin and thus less ambient noise,” he said.
Retaining the trust of airlines
To overcome some of these fundamental challenges when using commercial airliners for medical repatriations, Mauer said that it is critically important to gain and retain the trust of the airlines themselves – something that can take years of close cooperation.
Mauer explained that airlines are typically ‘very careful’ when approving the repatriation of a patient on a commercial flight. “The airlines must trust the medical supervision as well as the level of care and equipment allocated for the transport … it is [also] essential for the airlines to be convinced that the patient is stable enough for transporting, and must be assured that the medical crew is equipped and trained for
The airlines must trust the medical supervision as well as the level of care and equipment allocated for the transport
He added that airlines ‘may resist’ due to the perceived inconvenience of a medical repatriation for other passengers. However, ‘we have shown that with a bit of planning and taking other passengers’ comfort into account as part of that planning, it is possible to transport even complicated cases on a commercial aircraft’.
Mauer explained that ‘mutual trust’ was needed between the repatriation provider and the commercial carriers, and explained that his company has close relationships with a number of commercial carriers ‘who became familiar with our medical oversight and providers’. This familiarity enables repatriation firms to ‘secure all necessary approvals in a timely manner’.
In addition, Mauer said that a high level of trust can only be secured through expertise in dealing with each specific airline’s internal medical departments, backed up with a high level of medical expertise on behalf of the repatriation provider.
Despite limited space, no ‘compromise’ on levels of medical kit
Despite often having to overcome the challenge of managing a lot of equipment in the tight space of a commercial airliner, Era and Harrison and Mauer all affirmed that it is important not to ‘compromise’ on the basic level of provisions required. They did, however, acknowledge that while corners should never be cut, being flexible in the range of kit brought onboard to meet specific patient needs is sometimes necessary.
Medical repatriations via commercial airline can be like a swan gliding gracefully over the water, while paddling fiercely below the surface
“We … would never compromise [on what equipment was brought onboard]. This would impact patient safety and we will not allow that to occur,” said Harrison. “There are times we may bring additional equipment based on patient needs. Our minimum standard for commercial aircraft is to carry equipment and medications to provide basic advanced cardiac life support until the aircraft can land and local emergency services can arrive.”
Mauer agreed, adding that: “Sometimes there are cases when alternative solutions can be used. Our equipment is standalone so that we are not depending on the systems of the aircraft we meet onboard. This of course gives us more control and confidence for both patient, the aircraft operator and the insurer.”
For all three providers, a minimum level of equipment is required for the transport of patients on an airliner. Era outlined Capital’s minimal equipment list for a commercial repatriation:
- Diagnostic equipment such as pulse oximetry; a sphygmomanometer; a thermometer; stethoscope; and blood glucose monitoring
- Oral and intravenous medication for pain, nausea, glucose stability
- A venous access kit
- Advanced life support drugs and airway support such as iGels; oropharyngeal airways; automated external defibrillators; and oxygen delivery devices such as nasal cannula and masks
- Personal hygiene kit, including cleansing wipes; pads; vomit bags; a spill kit; clinical waste bags; sharps containers; and personal protective equipment.
However, he added that while additions could be made according to patient requirements, some patients needed such bulky equipment that they were automatically excluded from transportation by commercial flight, including: “Patients who require high concentrations of oxygen (above 6L/m) … as we generally cannot take large cylinders onboard and therefore we rely on a portable oxygen concentrator, which currently to best of my knowledge can only deliver 6L/m in pulsed mode and 4L/m in continuous. If a patient requires multiple infusions, there is nowhere to secure pumps.” Such patients will typically be transported instead by private aircraft.
Sometimes private air ambulance is the better option
While accommodations can be made to ensure the comfort of a wide range of patients and crew needs, it is also important to recognise when a private air ambulance may be more appropriate.
For Harrison, a key benefit of private air ambulances over commercial flights is the lack of an external, airline-operated medical clearance desk, enabling checks and assessments to be conducted internally by LIFESUPPORT. She explained: “With the air ambulance programme, we have our own internal medical control and assess if we can safely transport each patient.”
Era added that by using a private air ambulance, ‘we can take all of the medical kit required for the patient … and have the dedicated infrastructure to store it safely and conveniently for use’. In addition, he argued that for the more discerning or severe patient, using a dedicated air ambulance or private aircraft allows medical teams to have more control over their schedule, and often enables patients to be delivered much closer to their final destination by using smaller airports.
“Accessing an air ambulance or private aircraft is generally via a separate terminal designed for these aircraft so they will be smaller, less congested and the staff more familiar with the needs of these patients. Ambulances are more frequently allowed to drive airside so that the immobile patient can be loaded more rapidly either by stretcher or with the assistance of ground staff,” he said.
Multiple options mean the right solution for each patient
Ultimately, from patients’ perspectives, medical repatriations via commercial airline can be like a swan gliding gracefully over the water, while paddling fiercely below the surface. The benefits of the method are clear – more comfort for patients, more affordability and faster arrivals at destinations. Yet this is only possible with the efforts of repatriation staff in overcoming the challenges of small aircraft spaces, cautious airlines and airport security. Succeeding in this sector relies on the high standards, careful preparation and frequently, the polished social skills of staff.